I'm going to, I'm just going to put up some cases and just have you guys comment on it and just, you know, feel free from the audience if you want to stand up and use the microphone for any spine related questions. We'll try to hit some salient topics related to football and the spine. So first case, 31-year-old, complains of neck pain, no specific traumatic injury, imaging to the orthopedic eye looks, or the orthopedic sports medicine surgeon's eye looks pretty well aligned, flexion extension views, and we have this MRI which, let me see if I can point out on, basically the yellow arrow there showing a cervical disc. So Drew, you want to comment there, or David, just kind of your thoughts on what you're looking for and how you're talking to your sports medicine team when we have these cervical issues like this that come up. Sure. Presumably he presents and he just has neck pain without a neurological event, correct? And so what you're seeing on this MRI is that at C3-4 there's some degeneration of the disc and there's a disc osteophyte complex and significant spinal canal stenosis and cord compression and what it looks to be signal in the cord. I don't see a T2, I mean a STIR image, but don't you think that looks like a signal? I agree. So we call that myelomalacia, myelomalacia, softening of the spinal cord, if you will. And so that's a problem. That's a problem in a contact athlete and it's a real problem in a collision athlete. And so, you know, there's probably two different things going on. He could have neck pain from just his degenerative disc disease at C3-4 or also he has a little bit of a change at C5-6 and now you've gotten this MRI that shows something that is probably totally asymptomatic, but once you've seen it, you have to do something about it. And so, you know. So the myelomalacia pushes you a little bit more surgically in these cases? In my hands, yes. I would be, I'd be reticent to allow him to go back and play professional football without stabilizing that segment and decompressing it. It's a totally different conversation if he's an accountant. Right. Yeah. Yeah. At that point it's education, reexamination, come back. And how about the space available for the cord, the congenital kind of stenosis that or the congenital, you know, space available that we're all concerned about? How much does that play in to these decision makings or just in general with the football players? That influences things. I don't think this patient has congenital spinal stenosis. But in the presence of that, it certainly changes the conversation. And in the presence of congenital spinal stenosis, smaller problems lead to bigger issues than they otherwise would. But this is someone that, I agree with Drew, this is a very difficult situation to let this person play in the absence of surgery. So you're going to do an artificial disc? Because, you know, same age, an accountant who has, who has, you know, a neurologic issue, a myelopathy or a neurologic deficit, this is actually a great case for cervical disc arthroplasty. The young person where you're trying to limit the risk of adjacent segment degeneration over the long term, but, you know, not in the collision sport athlete. And to echo something that he asked, as he's given the talk about the cervical disc arthroplasty, and most of you people have been on an NFL sideline. In those collisions, there's no cervical disc arthroplasty that has ever seen that force coupling that you see on an NFL sideline. It just doesn't happen. And I think it's crazy. I know that I would have an ulcer if one of the guys I was standing on the sideline watching a game had a cervical disc arthroplasty and I was watching him play. I mean, shit, I'd burn a hole in my stomach. So single-level ACDF, what are the requirements for getting back to play? Does he have to have a CT scan showing fusion? Is it a clinical decision? When do we let these guys go back? I'm fairly biased on this. I always use, in an athlete, what I refer to as knuckleheads. So athletes, cops, and firemen. I always use Iliac crest bone graft for this kind of standard, old-fashioned, what's called a Smith-Robinson approach. It heals very quickly and it is robust. And these guys, despite you telling them that these are the post-operative guidelines, they do not follow them. I mean, maybe 10% do, but the first pro athlete I ever operated on was a hockey player. And I went down and saw him in the training room 10 days post-op and he had his cervical collar on, and he was riding an exercise bike, talking like this with his head turned all the way around backwards, and I almost passed out. And so you treat these people like they're county patients. You make it the most bulletproof as humanly possible, and they'll do well. I've never had a problem with donor site morbidity from an Iliac crest bone graft. Yeah, the literature says there's 30% rates of donor site morbidity, but I don't think that the world's a bell-shaped curve. So there are operators whose donor site morbidity rates are extraordinarily low. And so my perspective, and I agree with everything that you just said, but my perspective is the best way to do this operation is the way that you do it best. So if you are someone who consistently uses Iliac crest in your practice, and it's not the twice a year or three times a year that you're deviating from your typical practice to do something different, I think that there are people in the world for whom Iliac crest autograft is in fact the ideal procedure, and I don't think that that's the right answer across the board, because not everybody has minimal donor site morbidity. The other fascinating thing, which is why you use Iliac crest autograft, is that the healing rates of ACDFs in the elite athlete are significantly worse than the healing rates in the broad population of people who undergo ACDFs. So the published literature rates of pseudoarthrosis in ACDFs is two to 4% in the general population undergoing ACDF, and it's over 10% in the elite athlete, which is incredible, and it's for exactly those reasons, that no matter what restrictions you give them, they apparently don't seem to sink in, but there also, there's a reason why insurance rates drop at 25, because young males can't be trusted, right? That's a simple actuarial fact, that insurance rates drop at 25 because of the lack of trust in the young male. Well, these are predominantly young males who are undergoing this operation, and it's likely a direct correlation or causation between the significantly higher rates of pseudoarthrosis in this patient population and the actuarial realities of insurability. All right, we're going to jump to a new case, try to get through a couple more. Drew, this is yours. Sure. I can let you present it. Sure. Yeah. This is a baseball player, but the reason I brought it up, because it's a clinical pearl. I was taught by our neuroradiologist many years ago, and because of that, I probably find somewhere between 8 to 12 cervical disc herniations a year that I did not think existed because of the vagaries of an MRI, and so this was a professional shortstop. I was asked to see him, and he had weak triceps. It was probably four minus over five. It was his left arm. He's right-handed, and so that's his power stroke. We took him to get an MRI, and his MRI was totally normal. I mean, totally normal, and so not only did he have a C7 motor weakness, he had a little bit of a sensory loss, and I'm sitting there looking at this thing going, what in the world? I mean, he's got to have something, and at that point, the neuroradiologist said, well, under these cases, sometimes the way, because of the foramenal vessels or the vessels that exit in and out the neuroforamen, the vein and the artery, sometimes it creates a flow artifact that makes cervical disc herniations in the neuroforamen not seen, and so my boss I did my fellowship with told me this. Never let a test stand between you and the diagnosis, so we proceeded to an IV contrast CT scan, so sometimes I get an IV contrast CT scan, and sometimes I just get a myelogram and postmyelogram CAT scan, but if you look where the dye on this cross-sectional thing is the IV contrast, and what you see on the opposite of the area, the opposite area of that, you can see the dye is closely next to the vertebral body, and if you look where that arrow is, there is a small foramenal disc protrusion there that is compressing his seventh root, and without getting this test, I would have been unclear what was going on with this guy, and this was the highest-paid athlete in the world, and so it was a very important test to get, and so now I see, as I said, I probably see 8 to 12 disc herniations a year that I get either an IV contrast CT scan or a myelogram or CAT scan that have come in and seen me, and their MRI is totally normal, I mean totally normal, even after we get the test and find out that they have this foramenal disc herniation, sit down with the neuroradiologist, and we still can't see it, and so this is just another tool in your armamentarium. If you have an unexplained radiculopathy, get a contrast CT scan to look for a foramenal disc protrusion. And so non-surgically treated, had some injections, EGT, you know, gave him a selective nerve root injection, managed him, and he won the AL MVP that year with a weak tricep. So I test him, you know, every week for, you know, the length of the baseball season, six months, because this happened in spring training, and I could, I'm pretty big, and he's about my size, but I could push his triceps down, and despite that, he had 47 dingers. He was a great jungle cat. All right, we'll jump to a lumbar case here, and then maybe David will flip back to your case. So this is a 28-year-old practice squad offensive lineman, nonspecific back pain, two weeks. Drew, you kind of talked about this a little bit earlier, so we'll dive into the lumbar disease. You know, no flexion extension here. My untrained eye, I can't really see a PARS defect. Do you guys see anything differently there? I do not. Okay. So as you alluded to, maybe you guys want to comment on this, you know, this pattern of bone marrow edema and what we're seeing here on this MRI. I think that this is every season for virtually every team in the National Football League that one player will go through this, and this stress or edema that's in the PARS, we don't have all the imaging here, but I suspect that this is not yet produced a PARS fracture, that this is edema in the PARS, but I can't be certain from this. We want flexion extension films that can sometimes help elucidate that a little bit better. A CT scan is the definitive way of determining whether this is edema or whether it is a fracture. And, you know, I thought that was a fantastic summary that you presented on how to handle this. So looking at this MRI, typically when they come in and they're hurting, and if it's a fairly acute stress reaction, the edema is much more widespread than this. It's much brighter on a STIR sequence. And so at this point, I would recommend getting a CAT scan to assess it. And if it is a fracture, and so, you know, if you've looked at enough of these things, you can tell there are some that are chronic and they're corticated, which means there's no cancellous bone that looks like it can heal. So if it's completely corticated, you can make a fairly good statement that this is a chronic, and so a chronic fracture. And so these things truly are pseudarthroses. You know, if you look at the histology of a chronic PARS defect, you'll see nerve cells, you'll see some synovial cells. So it really is a false joint. And so they can become painful. And so if, let's just take this one step further. Let's just say that he did get a CAT scan. It did show this was chronic. My next step would be, let's inject those PARS defects. Let's put some steroid directly into it and manage his inflammatory component and work on his core and then get him back to play. I would have concern about doing that if it weren't a chronic defect. No, it's gotta be, you have to, point well taken. It has to be a chronic defect. You would never do a steroid injection and an acute injury that you think has a chance to heal. I think your comment about, and we had a player, maybe Drew, did we talk to Drew about it years back? We had that player with the chronic and then an acute. And then the acute, yeah. Yeah, I think it was acute. Our linebacker who played at Miami. Yeah, he had a, so we had, he went through this as in his collegiate career, fully recovered, finished his college career. And then he was three years in, or two, I think it was his second season in the NFL. It was the other side. Yeah. And then we successfully. Treated him. Successfully got him through it. We did consult Drew on that one. And then he played multiple more years in the NFL. All right, so we kind of exhausted that. Let's, let me jump to David, to your case. This is another cervical disc case. Treated with an ACDF. So yeah, David, why don't you talk us through this case? Ooh. All right, so this elite college player in a very routine practice collision, nothing you would ever think would be a problem. It was a, they just bumped into someone. They were running the route wrong and he collided with the linebacker, not even at full speed and was quadriplegic. And it was a neuropraxic event. And within minutes he was back to full strength and it took hours for the sensory symptoms to go away. But by the next day, it absolutely no manifestation of this at all. So they appropriately got x-rays, identified clipple file syndrome. And then that led to, you know, these additional pictures to get a better understanding of this. Clipple file syndrome is more common than people realize. You just have to look for it, but it has very characteristic manifestation. So if you go to the next slide. So just a little bit more, if you go back one. So just one thing that's on this other slide is at that level of C3-4 where the disc herniation is, he also has a nine millimeter canal diameter. And that comes into consideration later. So he has a hypoplastic C1 posterior arch. So he didn't fuse the posterior aspect of the C1 arch as is often the case in clipple file. So you get these craniocervical junction abnormalities. His C1 lateral mass is not normal and there's an aberrant occipital condyle to C1 lateral mass joint on the left side, a congenital fusion at C2-3 and now a disc herniation at C3-4 and the setting of congenital stenosis at that level inside of clipple file syndrome with spinal cord compression and a neuropractic event. All very simple. Yeah. Yeah, so yeah, what do we do here? I mean, this is, I mean, I guess for the non-spine surgeon, the question is, does this need surgery if he's recovered or, you know, then what type of surgery, kind of same algorithm that we take with most of our processes here. What are your guys' thoughts here? Well, so was he neurologically intact after this? Totally normal. No pathologic reflexes. Rock solid neurologically normal. Yeah, so can't play anymore. The question is whether he needs to have surgery now or just wait until he develops signs and symptoms. But for me, you know, having a C2-3 fusion is a problem. That puts a lot of, there's a huge force couple to occiput C1 and C1-2 and C3-4 and I have a rule called Tick's disease. Tick, T-I-C, spondylitic, kyphotic and stenotic. If you have those three things then you're disqualified as far as I'm concerned. You know, and so he meets that criteria. To me, the question is whether you operate on him now or not, I would probably just, I would withhold him from probably even contact sports, let alone collision sports and watch him and educate him. And, but you could make it just as good an argument to say I'm gonna do a fusion at C3-4. I'm not sure, I'd probably get a mologram and post-mologram CAT scan to assess the level below. Well, we did a C3-4 ACDF and this is the case where the most number of in-person additional opinions were sought. In the aftermath of this intervention, we waited three months to do the surgery. Surgery was done three months later and it was all with the understanding that our first approach was to do the correct thing for this individual as a human being. We needed to do the right thing for him as a person and then that football was completely off the table for the 2020 season and that we would have a reassessment of what this meant for his future for 2021 and beyond. And there were a number of voices and multiple voices had Drew's perspective on this. You actually were consulted on this case first. And- Did I say the same thing? You said the exact same thing. And so then here comes the challenge because this is a world-class athlete who at the time was being projected as a first-round draft choice and a year later he didn't heal. So what do you do? And so we have all these factors at play, the clipophile, the anomalies of the cranial cervical junction, the fact that ACDFs don't actually meaningfully change your canal diameter. It's not a procedure. If you want to change someone's canal diameter, you need to do a posterior approach. You can change someone's neural element compression from a disc, but you don't actually widen the canal with an ACDF. He did gain a millimeter, however, which is sort of important from- Changed his BMI. So what I did was I did kinematic testing and I had done this prior to surgery and so I've now started to do this on all of the elite athletes that I care for. And what I prove is that even if when the CT scan says that at the time there was a pseudoarthrosis, he has a functional fusion. So pre-op, he had motion at C3-4. That's the blue line. The black line is what our normative data indicates. And then post-surgery, there's absolutely no motion at C3-4. So even though a CT scan says that the inferior aspect of the graft hadn't fully incorporated, this is a functional fusion. And when we compare that against the other levels, you can flip through the next one. Like the other levels, what I also wanted to know, because now he has a congenital fusion at C2-3 and a surgical fusion at C3-4. And there is this dogma out there that a two-level fusion is a contraindication to return to play. But in my opinion, you have a God-given fusion and you have a surgical fusion. And that to me carries with it a different set of connotations. And I wanted to make sure that an additional level of fusion didn't change the kinematics and the dynamics of the other levels of his spine, which in fact it did not. So the C3-4 fusion did not introduce additional motion at the other levels of his spine. And I checked it in all, you can just keep flipping through it, because I checked it in all domains, in all vectors. So do you let him play? No. So he's still kyphotic. He's kyphotic from his occiput down to C4. And so, I mean, he's, you know, once again, I would get an ulcer standing on the sidelines. I've been around football the entirety of my life and this makes my stomach hurt. Yes, this is very difficult. It's about me, it's not about him. And so we solicited numerous voices. Fortunately, by two years he did heal. But at one year with a, at the time, a pseudoarthrosis with incomplete incorporation of the inferior aspect of the graft, we solicited numerous opinions. The lawyers were involved from the institution, for sure. The general counsel himself for this well-known football institution was a part of every one of these conversations. And in the end, this was a decision the player made. And he understands the risks involved. They have been clearly articulated to him. And there was not unanimity in perspectives. There were people with exceedingly strong credentials who saw and examined him and reviewed everything and came to the conclusion that this was an opportunity for him to play and there were others that said no. There was disagreement amongst the medical staff of the university as well. There were different opinions. And eventually the lawyers crafted a document that said that the player basically had to sign a contract saying you have undergone an extensive evaluation, you have received numerous opinions from many different people, you have been articulated what the potential risks are of returning to a collision sport, and we are allowing you to make this decision for yourself, which he did. And it meant that every Saturday of the 2021 season, I was taken a basket case. And that was very challenging to go through that. Every time they played, I knew exactly when the kickoff was. It was then college football games take forever, right? And so it was four and a half hours of pure agony. But he had a very successful season and put himself in a position to play in the NFL. Did he play in the NFL? I would just tell you, I mean, if someone asked me from the NFL team, do we take this guy as like, are you kidding me? Right. There's 30 guys who have the same talent as this guy, pretty close, and 29 of them don't have a auspice C-1 abnormality in a two level fusion. We saw him as well. I mean, everybody kind of downgraded him, but it was more of a question of- I think downgrading is a euphemism. Well, I think there are two concerns. With any of these players, is he at risk? Is he a catastrophic risk? Or is he just at higher risk for adjacent level ongoing problems? There's another thing about this, that on the CT scan, he had an incomplete ring of C-1. And I have two football players had incomplete C-1 rings that had C-1 fractures because of that. And so if I see someone with what's called a spondyloschisis or an incomplete fusion of the arch of C-1, I disqualify him. Getting a C-1-2 fusion, you're talking about changing the arc of your life. You go from turning your head like this to turning your head like this. And so getting a C-1-2 fusion changes your life completely. Now, you're not gonna have a major neurological problem from that, but your functional life is changed dramatically and your arc is just flattened. He's on an NFL roster. Yeah. You didn't play with the Cowboys. No. All right, well, this is great. I'm glad we introduced some fireworks. I think we'll wrap it up here and let everybody get to dinner. And unless there's other questions, if we got a minute or two, if anybody had something pressing, otherwise, we'll plan to wrap up again and meet again tomorrow morning for the upper extremity section. So thanks, everybody. Thank you.

spine

football injuries

surgery

MRI scan

treatment options

congenital fusion abnormality